Representative from the Audience
1. Under which circumstances is it permissible to refrain from commencing medical treatment for a terminal patient? E.g. resuscitation, artificial respiration, dialysis, radiation, chemo-therapy, intravenous nutrition or gastrostomy, intravenous liquids.
2. Are there situations where it is permitted to terminate treatment of a terminally ill patient?
Is it permissible to disconnect the patient from the respirator in light of severe suffering on his part?
3. What is the status of the family with regard to deciding whether to continue or terminate medical treatment?
Synopsis of the Responsa
Rabbi Zalman Nehemiah Goldberg
The Ban on Murder
Killing a human being is forbidden whether directly or indirectly (such as by poison or poisonous medicine). The prohibition applies equally whether the person killed is healthy, sick, or dying. As long as a person is alive it is forbidden to kill him, and this is the ban on murder referred to in the Ten Commandments.
Sources: Exodus 20:13; Rambam, Rotzeach 1:1, 2:1-7; Sefer Assia 4, pp. 260-262.
The Obligation to Save Life
There is a duty to save life. Anyone who is able to save another person’s life but fails to do so infringes the law “You are not to stand (idly) by the blood of your fellow-Israelite (Lev.19:16).” This applies, for example, to a doctor who fails to treat a patient properly, resulting in the patient’s death. He is a sinner, but not a murderer.
Sources: Lev. 19:16; Sanhedrin 73a; Rambam, Rotseach 1:14.
The Saving of Life Overrides the Sabbath
In order to save or extend a life, even temporarily, any ban in the Torah may be set aside apart from: idolatry, serious sexual offenses (adultery, homosexuality, incest, bestiality) and murder. The laws of the Sabbath may therefore be overridden to extend the life even of a person who is dying and has no chance of living more than a short period.
Sources: Yuma 83a-85b.
Removing an Impediment to Death
When someone is already dying but external causes, such as a loud noise or grains of salt on his tongue, impede his death, the noise may be silenced or the grains of salt carefully removed although we know that after removing the impediment he will die within a shorter time.
Source: Rema, Yoreh Deah, 339:1.
The Difference between the Duty to Extend Life and Permission to Remove an Impediment to Death
Permission to remove anything that impedes death appears to contradict the duty to extend the life even of one who is dying. Three different approaches have been adopted in explaining this apparent contradiction.
(a) The first approach considers whether or not the patient gains in any way from the extension of his life. If there is any useful purpose in extending his life, for example if he is conscious and able to think and maintain contact with those around him by speech or even by signal, there is a duty to extend his last hours even if he is dying and suffering. On the other hand if the patient gains nothing by a short extension of his suffering and his death is preferable to his life, there is no duty to extend his last hours. There is therefore no duty to extend the life of a terminal patient who is in the state of a “vegetable” or who is unconscious such that the extension of his life serves no purpose whatsoever.
(b) The second approach makes a distinction between saving a life by natural means, including the supply of basic necessities such as oxygen, liquids, food and medicine, and the interruption of external impediments to death without withholding basic necessities.
(c) The third approach distinguishes between normal treatment and special treatment. Normal treatment may not be stopped even if it involves breach of the laws of the Sabbath, but there is no obligation to provide special, unusual treatment. It is therefore essential to continue the supply of oxygen, liquids, food and normal medicines, but there is no obligation to operate on a dying patient or to apply resuscitation after his heart has stopped beating.
In this approach there are types of treatment that may be considered normal for one patient but special for another. For example, for one who is undergoing dialysis, such treatment is normal and must be continued to the very end. On the other hand one who is suffering from cancer which in the last days of his life spreads to his kidneys need not be treated with dialysis which can at best extend his last days a little since such treatment is regarded for him as special.
Sources: Nishmat Avraham 2, 339:4; Enc. Hilchatit Refu’it
s.v. lamut note 4 (pp. 401-416).
The Halachic Decision
If the conditions permitting non-treatment according to all three approaches apply, the treatment need not be given. Even when the third approach alone applies, non-treatment might be permissible since there are leading rabbis who have permitted this.
Source: Nishmat Avraham, ibid.
The Status of the Family
The family has no independent status in deciding whether treatment should be continued or not.
There are two reasons for this:
(a) The family has no right to ask the doctor to act contrary to the halacha.
(b) There are cases where the family has an interest in the patient’s demise.
Despite this, the family’s opinion should in practice be heard since they are most aware of the overall situation. There are other reasons to take their opinions into consideration. However, relying solely on the family can at times be dangerous. There have even been occasions when the patient himself, feeling that he is a burden on the family, has asked to die in order to relieve them of that burden.
In practice the final decision must involve detailed investigation and full consultation between the doctors, the family and the rabbis.
Source: Resp. Melammed Le-Ho’il 2:104.
General Principles vis-à-vis Halacha in Practice
These are merely general principles. In practice, each case must be considered independently on its own merits. The family should always consult someone suitable who understands both the medical and the halachic aspects. Such a person, after examining the situation in detail and clarifying it in his own mind, will be able to consult a rabbinical expert who will decide each case on its own merits.
Source: The First International Collquium on Medicine, Ethics & Jewish Law,
July 1993, pp. 338-341 (Schlesinger Institute, Jerusalem, 1996)
The problem, therefore, is to what extent and under which circumstances may one desist from treating a dying patient. It is obvious from what Harav Auerbach writes that a patient with Alzheimer’s disease or with severe cerebral damage, whatever the cause maybe, is still a human being in the fullest sense of the word, and must be considered as such in the context of active euthanasia. Furthermore, according to his view any procedure needed to nourish or sustain the patient must be carried out, even if this can only be carried out by artificial means. Thus, the patient must be given food and drink, even if this may be possible only by naso-gastric feeding tube, feeding jeujunostomy or total parenteral nutrition exactly as one would do for any other patient who needed this and who had a full chance of recovery. Similarly, the daily insulin requirements must be given, just as one must give oxygen and blood when necessary. I was recently involved in a case of a 68 year old woman who had been on a hemodialysis program for some eighteen months, and who collapsed with a large intracerebral hemorrhage and cardiac arrest. She was intubated and resuscitated. I asked Harav Auerbach whether dialysis should be continued on such a deeply comatose respirator patient. His answer was an unqualified yes; since she was already on such a program this was for her a “normal” procedure.
Many years ago a 63 year old man with end stage diabetic nephropathy, neuropathy, cardiomyopathy and retinopathy was admitted to my care. This blind man who had had a below-knee amputation for gangrene two years previously was admitted with sepsis, congestive cardiac failure and moist gangrene of the other leg. The chances of him living more than a few days without surgical intervention, was obviously nil, but, in view of his extremely poor general condition, the surgeons put his chances of leaving the operating theater alive as small. The man himself refused operation, and wished to be left to die. Harav Auerbach decided that we should not insist on the operation, since this would not be curative of the underlying condition, was highly risky, and would only add to his physical and mental suffering; in addition the patient himself did not want the operation. He died a few days later.
The Igrot Moshe also writes: If there is no known treatment available for the patient, and there are no means by which to relieve suffering, and all that can be done is to prolong a life of agony for a short while, one must not do so.
A general approach to the problem could therefore be summarized as follows:
(1) All patients must be given food, drink, oxygen and other norm- ally accepted life-sustaining measures, even if they have to be given in an unusual manner.
(2) A patient with a chronic, incapacitating, but not terminal illness (i.e. where speedy death is not anticipated), must be treated exactly as any other patient, and full resuscitative measures must be carried out if so required, even if thereby life is likely to be prolonged for only a short while.
(3) A patient with a terminal illness (i.e. is dying), must also be treated, as any other patient, in terms of daily sustenance and accepted medical treatment. However, if the patient is in cardiac and/or respiratory arrest, or develops a complication that requires major treatment programs that will add to suffering, then:
(a) If the arrest is because of the terminal disease as expected in the natural course of the illness, one need not resuscitate, and indeed it may be wrong to do so. Also desperate major measures to prolong the final inevitable death process, which will only add further agony and suffering, are not called for.
(b) If, however, the arrest arises unexpectedly, from a cause unrelated to the underlying disease, or if a complication develops which is unconnected to the disease, full treatment must be given as for any other patient unless this will cause further suffering to the patient over and above that of his basic disease (see quote 21 above).
Thus, in summary, all patients must be given normal sustenance and treatment. The majority of patients should be treated, as indicated, even by major medical or surgical intervention including resuscitation. There will be a small minority of patients (group 3a mentioned above) in whom major intervention and resuscitation would not be appropriate.
Though it is obvious that no two patients and no two cases are alike, it cannot too strongly be made clear that every problem of decisions relating to life and death as enumerated above must not be made without prior consultation with a recognised Rabbinical authority. There is nothing more final than murder.
I must, at this point, add something that in my experience I have found to be easily forgotten or overlooked. The patient is suffering from a terminal illness and is about to die in a few hours or days (group 3a above), and for whom the medical profession has nothing further to offer. Such a patient should be made as comfortable as possible, and treated with the maximum of TLC, tender loving care, including morphine or its equivalent to relieve pain, but not for the purpose of ending life. Once such a stage, based on the realisation that nothing further of value can be done, has been reached, a second order must be passed on to all involved in the patient’s care no further tests or examinations! Is there any point in routine pulse, temperature or blood pressure recordings, not to speak of blood tests, once such a point has been reached when nothing further of value can be done regardless of any change in the patient’s condition? Certainly, if done on the Sabbath, it would be a pointless desecration of the Sabbath. Finally, when close to death, the patient may not be moved or touched. [This obviously does not apply to a patient who may still be viable].
What about the baby born with an untreatable rapidly fatal heart defect? Or the anencephalic baby? Are they considered “alive” and therefore everything necessary to keep them alive must be done for them on the Sabbath? Or are they to be considered as already “dead” (since we know that they will not live for 30 days), meaning not only that nothing must be done for them on the Sabbath, even if this involves a Rabbinical prohibition only, but also that organs may be removed from them for transplantation even in the presence of spontaneous respiration and heart beat? The Talmud states: Under certain circumstances a baby born in the 8th month of gestation is likened to a stone, and may not be moved (on the Sabbath), but the mother may lean over him so that she may suckle, because of the danger. Rashi explains that “danger” refers to the mother, since excess of milk may lead her to illness. Thus, at first sight, we see that were it not for the mother’s suffering, then at the time of the Talmud, a baby born, under certain circumstances, at eight months of gestation would not live for 30 days, was considered to be already “dead.” Thus one may not desecrate even the Rabbinical ordinances of the Sabbath in order to feed it. However the Yad Rama and Rashi elsewhere both explain “the danger” as being applicable to both the baby or the mother. Therefore Harav Auerbach explains the Gemara to mean: (a) that only in such a case where the baby lay motionless and unresponding “like a stone,” and (b) when it was premature; only in such a case would it be prohibited to desecrate the Sabbath even if by so doing one might prolong “life” by a few hours or days, remembering that we are referring to a baby who is held definitely to die within 30 days. However, if the baby moves and responds to stimuli, then it should be treated as normal even if it is certain that it will live for only a few days, and even if it means desecrating the Sabbath. This is all the more so if the baby were born at term.
The anencephalic child (both complete and incomplete) will certainly die within 30 days of birth, and 99%, within 72 hours. However, it will move its’ limbs, make crying noises and suck (all of these are spinal reflexes since no cerebrum is present). Harav Zilberstein has stated that it would be permissible to abort such a fetus since it is not considered alive, and is within the category of a “nevelah.” His ruling is based on the Gemara and Rambam that such a fetus, when born, does not render the mother ritually unclean. What, however, is its status once born? The Pitche Teshuvah quotes the ruling of the Tshuvah Me-Ahavah, a member of the Beth Din of the Noda Be-Yehudah who ruled that the fact that a child does not render the mother ritually unclean as a result of its birth , does not mean that one has the right to kill it. To kill it would be tantamount to murder, though this be brought about passively, such as by starvation. On the contrary, death by starvation would be worse, for the sin of cruelty would be added to the sin of murder. Harav Auerbach concurs with this ruling of the Tshuvah Me-Ahavah, and wrote me that even though it would probably be permissible to abort such a fetus, but once born, it may not be killed, and one would have to desecrate the Sabbath on its behalf if necessary, especially if it were born at term. However, if such a baby stopped breathing or suffered cardiac arrest, resuscitation need not be carried out.
As I have written above, there are many problems and apparent contradictions, just as life itself is full of contradictions. Our approach to these problems of life and death should be with humility, and the realisation of our fallability and lack of absolute knowledge, with complete acceptance of the tenets of the Torah as expounded by our Sages, with the readiness to listen to and put into practise what they tell us, and with the willingness to control our emotions, even those of pity and compassion, within the boundaries set by the Torah. Only thus may we again achieve the heights we all reached at Mount Sinai when as one, we vowed “Naase Ve-Nishma.”
It behooves us all to read and read again what the Rambam writes: “It is fitting to give thought to the Laws of our Holy Torah and to delve into their meanings to the best of our ability. And, if one does not find a logical reason for or does not understand something, it must not then become unimportant in one’s eyes. One must not attempt to reach the understanding of the Almighty since this will surely lead to harm; neither must one think of the Torah with the same human “logic” with which one faces one’s daily problems. Come and see how strict the Torah is with the Laws of wrongful use of things that were sanctified. If sticks and stones, dust and ashes, once a human being has dedicated them even by word of mouth only, become truly sanctified, and one who desecrates such sanctity is held guilty, and is required to bring a sacrificial offering, even if the act were unintentional, then how much more so that the commandments that were given to us by the Almighty may not be transgressed and belittled, just because we do not fully understand their meaning,” etc.
In the modern world of fast-moving technological medicine in which we live, where today’s taboo is tomorrow’s routine, and where yesterday’s unthinkable becomes today’s debatable and then tomorrow’s unexceptional, we, as religious and believing Jews must strengthen and reaffirm our faith in the Almighty and His Torah, as the ultimate, and indeed the only way to lead and shape every part, not only of our lives, but also of our very thoughts. This is incumbent on us even if it forces us to reach the unpalatable realisation and conclusion that we are fallable in our logic and understanding.
òì ëøçê àúä çé åòì ëøçê àúä îú åòì ëøçê àúä òúéã
ãéï åçùáåï ìôðé îìê îìëé äîìëéí ä÷ãåù áøåê äåà
Source: ASSIA – Jewish Medical Ethics,
Vol. I, No. 2, May 1989, pp. 36-39